Find out when home care works best and how better funding could make it an option for more seniors.

Imagine abandoning the place you’ve called home for the last 40 years, surrendering all your income, and moving into a long-term care facility—a “nursing home”—where you must share a room with a stranger. For more than 1 million older Americans, this is—or will be—reality as they age and become too ill or frail to live independently. Most adults vehemently state that they do not want to end up in a nursing home. However, for many, a long-term care facility may be seen as the only option. Eldercare and its financial implications represent a significant societal issue as the American population ages—and the aging population continues to rapidly increase.

Statistics from the U.S. Census Bureau indicate that the population of individuals aged 65 and older will increase to 40 million by 2010 and 55 million by 2020, and the population of individuals aged 85 and older will increase to 6.1 million by 2010 and 7.3 million by 2020 (American Association of Retired Persons [AARP], 2006). Will our society be able to provide appropriate personal and medical care to such a burgeoning senior population?

“Projections for the future are particularly alarming,” says Kathy Black, PhD, MSW, assistant professor in the School of Social Work and Hartford geriatric social work faculty scholar at the University of South Florida at Sarasota/Manatee. She has worked with seniors and their families for nearly 30 years as a nurse, social worker, and geriatric case manager in acute and long-term care, institutional, and community-based settings. “The costs of long-term nursing home care will exponentially increase to meet the needs of the aging Baby Boomers. That is why there are enormous efforts—both public and private—to stave off the high costs and keep people at home with some supports at a fraction of the cost of institutional long-term care,” she explains.

Over the past decade, assisted living communities and home-based care have increased substantially, but although the number of older adults living in nursing homes has decreased slightly over the past decade, a majority still live in such facilities (Harrington et al., 2005). As the Baby Boomer generation ages, alternatives to long-term care will be sought, and home care is expected to be a popular option. “Concepts such as ‘naturally occurring retirement communities,’ ‘aging friendly communities,’ and other developments such as assisted living facilities and private long-term care insurance are growing to keep seniors in preferred community-based settings of care,” says Black.

Pushed Into a Nursing Home?
Even with these community-based alternatives, many seniors may still feel pushed into a nursing home due to personal circumstances, such as lack of finances for home care services and limited informal supports. The AARP notes that nursing home care is a mandatory Medicaid benefit, but Medicaid funds only limited community-based long-term care services. Approximately two thirds of Medicaid’s long-term care funding is for institutional care. Although spending on home- and community-based services increased more than 80% between 1998 and 2003, only approximately 20% was directed toward those aged 65 and older. The AARP also recently reported that, from 1993 to 2002, Medicare home health visits per user declined in every state, and the overall average decrease in home visits was 47% (AARP, 2004).

Lack of financial resources to remain at home represents a critical factor leading to nursing home placement, says Black. Valerie VanBooven, RN, BSN, PGCM (professional geriatric care manager), author of the book Aging Answers: Secrets to Successful Long-Term Care Planning Caregiving and Crisis Management, helps families plan ahead for long-term care needs or manage the crisis of long-term care. VanBooven says, “The push to nursing home care starts with the Medicaid system. It traditionally has been easier to get Medicaid to pay for services in a nursing home setting, although that has changed somewhat over the years.” Because our society requires that most families have two incomes, most adult children are unable physically or financially to care for their aging parents at home, she says. Although costs vary by state, Medicaid pays upwards of 90% of nursing home beds, Black adds.

Other important factors that contribute to nursing home placement, Black says, include health status and limited informal social support networks to provide care necessary to stay at home. Availability of adult children and other caregivers, such as siblings and friends, in terms of geographic location and daily free time, often influences nursing home placement, she adds.

“Studies have found that multiple reasons ultimately account for nursing home placement—physical health and self-care abilities, caregiver stress, and available resources are predictive of placement. Particularly, people dependent on others for activities of daily living, such as bathing and eating, will require 24-hour care or supervision at home, which often leads to increased caregiver stress,” Black explains.

When a primary caregiver is also an older adult, such as a spouse or partner, they may become unable to continue providing care at home by becoming ill, says Forrest Hong, PhD, LCSW, CMC, chair of the aging practice section of the National Association of Social Workers and president and CEO of Senior Savy, a Southern California company that provides personalized eldercare solutions. Hong has more than 20 years of experience working with seniors as a social worker in outpatient psychiatry, internal medicine, geriatric assessment centers, inpatient psychiatry, skilled nursing and residential care consultations, geriatric care management, private home care agency, and as a caregiver trainer.

For older adults with medical conditions requiring 24-hour care and/or those lacking an appropriate home support network in the family, a nursing home may be the best alternative. However, a nursing home environment is not necessary for many seniors. Several factors may cause seniors to be inappropriately placed or driven into nursing home care, says Hong. Lack of accurate information and assistance in decision making can result in inappropriate nursing home placement, he says.

“A family’s decision may sometimes be based on poor advice from other family or friends who do not understand what is really happening. In other cases, nursing home placement occurs because the aging parent has not communicated their own long-term wishes to the adult children. At other times, placement into skilled nursing occurs because the family does not believe they have the funds to pay for in-home care and may not fully understand all their options,” Hong explains.

Inappropriate placement may also occur when an older adult who does not have a medical condition requiring 24-hour skilled care ends up in a nursing home facility. In many of these situations, families have placed a parent with a diagnosis of dementia in skilled nursing because they are confused and noncompliant. Cases like this can be managed in the home, says Hong.

In cases where older adults have a medical condition, such as Alzheimer’s disease or poststroke impairment, families may consult with their physician for advice on long-term care. Do medical professionals push long-term care rather than home care? “In the past four or five years, I have seen fewer medical professionals recommending skilled nursing and more are suggesting in-home care first and assisted living as a second option,” says Hong.

According to Black, community-based case managers focus on keeping people at home. “Many public agencies, such as area agencies on aging, fund programs for home-based care,” she says.

Medical professionals that do recommend placement in a nursing home may not be pushing for a long-term care setting, but rather responding to pressures from the family to place a parent in long-term care or to the older adult’s living situation. “Sometimes, this recommendation may be against their own better judgment of the situation. But the physician may give in to the family. Or a physician may determine that the current caregiver is not physically able to provide care and may therefore recommend a long-term care facility,” Hong explains.

Deciding on nursing home vs. home care is an individualized decision that must consider the unique personal and medical needs of each older adult. “In considering home care for any older adult, needs must be determined along with realistic plans for meeting those needs,” Black says. “Factors contributing to meeting individual needs that should be considered in any decision include availability of informal supports, financial resources to pay for necessary services, familial and cultural aspects of beliefs, feelings about remaining at home vs. living in a long-term care facility, and expectations toward care at this stage of life,” she notes. Maintaining quality of life for the older adult—no matter what the care setting—should be an important consideration.

Home Care vs. Nursing Home Care — Comparing Quality
Can home care really provide the same or better level of medical care for older adults who may require more medical attention? “Five or six years ago, I would have answered ‘no’ because the level of services for seniors wanting to age in their home was not as accessible as it is now,” says Hong. Shorter hospitalization times and improvement in rehabilitation services for older adults have influenced the move toward home care, he believes. “In addition, the home care industry has become more competitive, creating an opportunity for consumers to have more than one or two choices. Today, there are more home care and home health services that can help older adults stay in their home. And the availability of palliative and hospice care has also improved the quality of life while continuing to live at home,” says Hong.

Whether home care can provide the same or better level of medical care for those requiring medical attention depends on the specific needs of the individual senior, says Black. “Generally, home care can meet the needs of many people as they age,” she says.

For many older adults, even those with medical conditions, to remain living independently, they may simply need some assistance with activities of daily living, such as transportation to medical care providers and shopping assistance. Others may need assistance with personal care activities, such as bathing and hygiene, while others with progressive dementia may require 24-hour supervision. All levels and types can be provided at home, says Black.

A primary benefit of home care is psychological—being able to maintain some degree of independence and sense of control over one’s life. “You simply cannot put a price on being able to remain in the home … especially those who have lived in their homes for many, many years. But even for others who do not have ties to a particular residence, the ‘sentiment of home’ is significant and defining for most people, and it signifies independence to many,” says Black.

Hong prefers that clients who require hospitalization return home to convalesce. “I believe the psychological benefit is greater from the one-on-one [home care], and there is a greater sense of control. They feel their needs are responded to quicker, and they will feel the level of care is better,” says Hong. The results of a recently published study found that older adults with acute conditions, such as pneumonia, chronic heart failure, and chronic obstructive pulmonary disease, benefited more from hospital-level care provided in their home (Leff et al., 2005; Leff et al., 2006). Researchers reported that hospital at home care was less expensive and patients had fewer complications than for in-hospital care; patients and their families reported being more satisfied with care at home.

Living in a familiar environment while recovering allows older adults to feel independent. “Choosing to receive care in their home helps them feel a sense of control—they can select who they want to provide care for them, whereas in a facility, they would have little to no choice,” says Hong. Routine and familiar surroundings can facilitate recovery. There are benefits associated with a familiarity with surroundings and retaining control of routine, he says.

“The benefits of home care are unmistakable. People heal better in their own homes, sleeping in their own beds. The familiarity of the home setting is comforting,” VanBooven adds. Aging adults with Alzheimer’s may have trouble learning anything new (ie, in moving to a long-term care facility), but can often, with the right care, thrive in their own familiar home environment, she says. “Maintaining some level of independence and control is also very important to seniors. Sitting in their own recliners with their own remote controls, watching their own shows is very positive, especially for those who have an impairment,” VanBooven notes.

While older adults receiving home-based care do not have to worry about sharing recreational activities, eating facility-planned meals, or picking up an infectious disease from other nursing home patients, Hong says, there are disadvantages to home care for older adults with health issues. Ongoing medical treatments delivered in the home can become expensive. And protocols for addressing certain health issues, such as infection control, may be difficult to adhere to in the home environment.

Black also says there are barriers to many home-based services. “Fragmentation, eligibility, and availability [of services] are all issues. Many older adults wait on lists for years for limited home care services,” she says. Because older adults may have different needs, ranging from medical care to assistance with household activities, several different service providers may be required to meet these diverse needs in the home.

Home Care vs. the Nursing Home — Comparing Costs
For many aging adults, home care can cost substantially less than a long-term care facility. In many cases, older adults may not require skilled nursing care, just some support with medication management, transportation to healthcare appointments, and weekly errands such as grocery shopping. However, the older adult and family members may mistakenly believe a nursing home is the only available option.

Annual costs of nursing home care are approximately $60,000 and variable by state, says Black. “That works out to about $180 per day. However, in states like New York and California, nursing home costs rise to about $300 to $400 per day,” VanBooven adds. A large disparity currently exists between the costs of long-term care and the income of older adults. The AARP reported that the 2004 median income was approximately $21,000 for men aged 65 and over and $12,000 for women aged 65 and over.

“Most seniors are surprised to learn that Medicare covers less than 3% of long-term care and under very limited circumstances,” Black notes. Medicare coverage is generally limited to transfer from an acute hospital within 72 hours and requires documented skilled needs in nursing and other therapies. “Coverage usually extends up to 100 days with days 1 to 20 covered at 100% and 21 to 100 at 80%, but that is only if the individual is still benefiting from skilled care—and that needs to be documented,” she adds.

“Anyone who works with seniors needs to understand the financial implications that long-term care has on families. Social workers, care managers, and others need to understand what long-term care insurance is, how to buy it, when to buy it, and if a senior even has a long-term care insurance policy. Also, they can help seniors understand their benefits and when they should be used,” VanBooven explains.

Long-term care insurance may or may not include home-based services. While many states have developed financial assistance for home- and community-based eldercare, financial hurdles still exist. For many older adults without a diagnosed medical condition, who still require assistance due to physical frailty or declining mental status, Medicare/Medicaid and other insurance plans may not adequately fund home care.

When support is only required during the day, home care costs much less than a nursing home. “Home care is less costly because it is not always around-the-clock care. A family may spend $5,400 on nursing home care, but only $2,500 on home care because only care during the day is needed,” VanBooven notes. “When the senior needs care 24 hours a day, even at home, that is when the costs become comparable [to nursing home care].”
“Home care can cost $17 to $25 an hour, or $125 to $200 per day, for live-in care. Nursing care after Medicare runs out costs approximately $130+ per day,” Hong estimates. When an aging adult needs more than five to eight hours of care per day and around-the-clock care is needed, the cost can rapidly become higher than the daily rate for nursing home care. Affordability for home care then becomes a factor, VanBooven says.

Societal efforts are underway to help finance better home care in preparation for the large aging Baby Boomer population. Results of a three-year Medicare-sponsored study of adult day healthcare vs. home health services should be available soon. If implemented, such a program is expected to offer expanded Medicare home care benefits. In addition, Medicare will also allow and pay for home visits from doctors who specialize in homebound older adult patients. Home telehealth visits are also being investigated by Medicare to provide health monitoring and home care, especially in rural areas where access to home healthcare agencies may be limited.

— Jennifer Sisk, MA, is a suburban Philadelphia-based freelance writer with 15 years of experience as a writer and research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.

Managing Home Care
Forrest Hong, PhD, LCSW, CMC, chair of the aging practice section of the National Association of Social Workers and president and CEO of Senior Savy, a Southern California company that provides personalized eldercare solutions, suggests that older adults considering home care consider the following issues to facilitate successful home-based services:

• Use a professional care manager, preferably one trained as a social worker, to help evaluate and coordinate home care services.

• For senior homeowners, use the home to help finance in-home care through a reverse mortgage or equity loan.

• Use only home care agencies that are licensed and bonded and verify that background checks are performed on all employees. “The senior should feel comfortable with the agency,” says Hong. In some cases, medical professionals can recommend agencies they have worked with successfully in the past. Agencies are ideal for providing home care when there is a need to cover a variety of shifts and hours, says Hong. In comparison to having an independently employed caregiver, agencies can make sure care is not interrupted when a caregiver is sick or needs time off.

• Understand the legal aspects of employing a caregiver in the home, especially labor laws. In some situations, hiring a 24-hour live-in caregiver does not necessarily mean that 24 hours of care will be delivered, since the worker is allowed to have breaks and sleep time, Hong points out.

• If staying at home is not an option, consider residing in a community residential setting, independent or assisted living. Often, skilled nursing care is available in a setting more like a home than a facility.

For the layperson and consumer, Hong suggests the book Eldercare for Dummies by Rachelle Zukerman.

According to Kathy Black, PhD, MSW, assistant professor in the School of Social Work and Hartford geriatric social work faculty scholar at the University of South Florida at Sarasota/Manatee, support and resources for remaining at home are available from a variety of governmental programs at the national, state, and local levels. “For example, the Administration on Aging funds area agencies on aging throughout the country and supports information and referral services, congregate dining and home meal delivery, caregiver and respite support, and other home care services. Medicaid also offers home-based services to divert from nursing home care,” she notes. “Home care assistance may also come from home healthcare agencies that can provide variations on home and personal healthcare; local senior centers and programs can augment services as well. Private, not-for-profit care organizations like the Alzheimer’s Association can also provide supports to remain at home.”